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EMPLOYMENT APPLICATION FORM POSITION APPLICATION 1. POSITION APPLIED :
perawat anestesi
DATE OF INTERVIEW
11-Dec-20
2. HOW DID YOU FIND THIS VACANCY ? LinkedIn
Recruitment Agency/Headhunter
Direct Application
Facebook
Jobstreet
Staff Referral
Others, please mention ____________
PERSONAL DATA 1. FULL NAME
Ficky Muhammad haryudi
2. SEX
laki laki
3. PLACE DATE OF BIRTH
Pandeglang
4. DATE OF BIRTH
12/1/1991
5. MARITAL STATUS
menikah
6. RELIGION
Islam
7. NATIONALITY
Indonesia
8. ID CARD/PASSPORT NUMBER
3602150112910000
9. NPWP NUMBER
808334536419000
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 11. CURRENT ADDRESS
jl.salemba bluntas gang H.murtado 8 no.A696
12. PERMANENT ADDRESS (AS PER ID CARD)
Kp.pasir degung, kec.warunggunung, kab.lebak, prov.banten
13. CONTACT NUMBER
MOBILE 1 082298714364 MOBILE 2 RESIDENCE
14. EMAIL
[email protected]
15. SOCIAL MEDIA
LINKEDIN FACEBOOK Ficky Haryudi INSTAGRAM
ficky_haryudi
TWITTER
FAMILY INFORMATION (for married individual, please fill in spouse & children data) No
Name 1
intan lauwanda
Sex perempuan
Relationship
Education/ Occupation/ Company
istri
S2/Guru/ SMPN 6 depok
PARENTS AND RELATIVES DATA (for single individual, please fill in family members information) No
Name of Parents and Relatives
1
duddi saprudi
2
rosikah
3
ficky muhamad haryudi
4 5
fifi fatmawati rahayu arya cembawan wijaksana
Sex
Relationship
Date of Birth
City
Education/ Occupation
laki laki
ayah kandung
6/7/1960
pandeglang
SMA/Wiraswasta
perempuan
ibu kandung
10/9/1965
pandeglang
S1/guru
laki laki
anak pertama
1/12/1991
pandeglang
S1/perawat
perempuan laki laki
anak kedua anak ketiga
9/1/1997 10/4/2003
pandeglang pandeglang
S1/perawat kuliah/pelajar
EMERGENCY CONTACT No
Name
Relationship
Address
Phone Number(s)
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP
1
1
intan lauwanda
istri
8979996946
jl.program IVB pancoran mas depok
FORMAL EDUCATION No 1 2
School/ Institution
City
akademi keperawatan yatna yuana lebak banten universitas esa unggul jakarta barat
Year of Graduation 2013 2019
Major keperawatan kesehatan masyarakat
Qualification Obtained keperawatan K3
GPA 3.29 3.02
LANGUAGE No
Language
1
inggris
Spoken moderate
Written moderate
Reading moderate
(Low/ Moderate/ High) (Low/ Moderate/ High) (Low/ Moderate/ High)
PROFESSIONAL LICENSES OR CERTIFICATION No
Name of Certification
1
BTCLS/BCLS
2
Anastesi
Name of Institution pro emergency
Years Obtained 2017
RSUP.dr.Sardjito Yogjakarta 2017
WORK EXPERIENCE Current Company rumah sakit royal progress
Company Name Company Address Latest Position
Sunter Paradise 1, Jl. Danau Sunter Utara, RT.6/RW.12, Sunter Agung, Tj. Priok, Kota Jkt Utara, Daerah Khusus Ibukota Jakarta 14350
perawat anastesi
Date (DD/MM/YYYY)
Start Date
2020
Starting Salary Latest Salary
8000000
Reason for leaving
mencari pengalaman yg lebih baik
End Date
sekarang
End Date
01-Sep-18
8500000
021-6400261 May we contact this current/ previous employer directly? If yes, please provide name, contact number If not, please explain why Achievement(s)
Previous Company rumah sakit sint carolus jakarta pusat
Company Name Company Address Latest Position Date
jl.salemba raya no.41 jakarta pusat perawat anastesi (DD/MM/YYYY)
Start Date
2013
Starting Salary Latest Salary
4500000
Reason for leaving
menyelesaikan skripsi karena sedang kuliah
6000000
021-3904441 May we contact this current/ previous employer directly? If yes, please provide name, contact number If not, please explain why Achievement(s)
menjadi asisten dokter anastesi konsultan anastesi nyeri, dan regional.
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP
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Previous Company Company Name Company Address Latest Position Date
(DD/MM/YYYY)
Start Date
End Date
Starting Salary Latest Salary
Reason for leaving May we contact this current/ previous employer directly? If yes, please provide name, contact number If not, please explain why Achievement(s)
ORGANIZATION STRUCTURE (please draw organization structure showing your position in your current company) kepala anastesi
dokter anastesi
perawat anastesi
saya
REFERENCES List two person NOT related to you, who are familiar with your character, background or work performance (preferably your direct supervisor) indah
Name : Company :
Contact No : Job Position : Years Known : Relationship :
Name : Company :
81299065328 perawat teman
Contact No : Job Position : Years Known : Relationship :
CURRENT DETAILS OF SALARY AND BENEFITS 1. Monthly basic salary gross
8000000
IDR
2. Eligible for over time ?
yes
( Yes / No )
If yes, monthly average ? 3. Allowances Meal
2000000
Transportation
800000
IDR
Phone/ Handphone
300000
IDR
Others
IDR
4. Loan facilities Type of Loan
Housing
Car
Outstanding Amount
Personal Max Limit
Interest per Year
% Outstanding Period Repayment Methods
5. Annual Leave
100000
(Days)
9000000
IDR
(months/ years) (months/ years)
6. Annual Bonus : THR (Festive Allowance) Performance Bonus
IDR
Others, please explain
IDR
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP
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7. Medical Benefits
Cashless
Reimburstment
Out Patients (Per Year)
IDR
In Patients (Room & Board)
IDR
8. Life Insurance 9. Other Benefits, Please Explain:
80000 IDR BPJS kesehatan dan kenagakerjaan
COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT 1. Monthly salary (Gross)
9500000
IDR
2. Benefits / Others 1 januari 2021
3. If you are offered employment with us when can you start work (or notice period) ?
DECLARATIONS AND AUTHORIZATIONS 1. Do you have any family members; as an employee, who working in this company? (Yes/ No) If yes, please state the name of the employee, designation and relation.
yes, yohana dan indah mayapada kuningan
2. Have you ever been dismissed or suspended from any position, or subject to internal disciplinary action by any of your previous employers? (Yes/ No)
No
If yes, please state where, when and cause
3. Have you ever been convicted of a criminal offence anywhere in the world, excluding convictions that have been set aside or quashed? (Yes /No)
No
If yes, please provide details.
Disclosure of a criminal record will not necessarily disqualify you for employment. However failure to disclose such information may result in disqualification of your application of dismissal from employment at MAYAPADAHEALTHCARE GROUP 4. Have you ever apply/ work in MAYAPADA HEALTHCARE GROUP? (choose one) (Yes/ No) If yes, When ?
For position ?
Where
Last selection stage (for apply)
No
5. Are you currently holding any position in any political party or a candidate for any political office? If yes, please provide the detail of position and political party and your joining date to that political party and the position that you are running for as candidate.
6. Is there any member of your immediate family an official or any government agency, an employee of any government agency, an official of political party, or a candidate for political office?
No
If yes, please states the detail of the name, position/office held and the family relationship. Immediate family means husband, wife, children, mother, father, siblings.
7. Do you have any other job or business activities outside the current employment?
No
If yes, please provide the detail including name of enterprise, type of business, position and starting year of the position.
I certify that all the information provided on this application is true and complete to the best of my knowledge. I understand that any false information or omission may lead to disciplinary action or summary dismissal without any compensation. I authorize MAYAPADA HEALTHCARE GROUP to verify all information provided in this application, including employment history, educational background and references. I authorize my previous employers and references indicated above to release any information they may have about me. MAYAPADA HEALTHCARE GROUP will only use information collected in connection with my employment with MAYAPADA HEALTHCARE GROUP.
Signature & Name
To the extent required by law, you may request to review and correct personal data through the HR Department. EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP
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